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LECTSTEPHEN
Assessment &
Reasoning GI
System
Peggy Scott, 48 years old
Suggested GI/GU Nursing Assessment Skills to Be Demonstrated:
GI/GU:
Inspection: skin (coloration, vascularity, striae, scars, lesions, rashes)
Contour from 2 angles – (flat, rounded, scaphoid, protuberant/distended)
Note symmetry, color, veins, lesions, scars, hair distribution
Umbilicus – contour; Note: inguineal or umbilical hernias
Symmetry (relaxed, supine position)
Abdominal movement during breathing
Aortic pulsations
Auscultation: (completed before palpation/percussion to not alter bowel sounds)
Bowel sounds – 1 minute per quadrant up to 5 minutes with the diaphragm
Intensity, pitch, frequency
Vascular sounds – listen for bruits in abdominal aorta with bell.
Palpation:
Light palpation to all quadrants – 1 to 2 cm to detect tenderness
Deep palpation to all quadrants – 5 to 6 cm for masses (location, size, shape, pulsatility, mobility, tenderness)
Palpate bladder- light palpation ONLY; you only want to assess to see if it is distended
Check for costovertebral angle tenderness
Make Learning Active!
Role play or go through the interview/body assessment process – student to student or as a group.
Review the case study as an application exercise in small groups or together as a class.
Depending on your program, some content in the case study may not have been taught. Do not let that
prevent you from utilizing this case study! Use it to promote learning by having students identify what
they do not yet know and guide where they can find the information in the textbook or on the internet
to address knowledge gaps. This is educational best practice and another way to scaffold knowledge!
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Present Problem:
Peggy Scott is a 48-year old African American woman who came to the emergency department because she is having
severe abdominal pain radiating to the back that started 24 hours ago but has become progressively worse in the last
couple of hours. She is now nauseated and states that she has “puked small amounts of green liquid” five times in the last
four hours. She had two loose stools today that were dark brown or black in color.
Peggy has struggled with ETOH use/abuse most of her adult life but has been sober the past six months. She begins
to cry and tells the nurse that this week was the one-year anniversary of her only son’s death in an automobile accident.
She reports that she has been drinking one liter of vodka daily the past week.
What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
Severe abd pain that radiates to Patient is experiencing severe abdominal pain and is
back vomiting green liquid which may indicate an issue with her
vomiting green liquid x 5 pancreas due to the nature of the pain radiation. Pt has a
loose stool history of ETOH abuse, drinking 1 L of vodka per day. Pt
History of ETOH struggles with depression after loss of her son in MVA
loss of son in MVA
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Class: Mechanism of Action (own words):
Depression Ibuprofen 600 mg NSAIDs inhibits action of prostaglandins, results
Low back pain PO three times in anti-inflammatory response, reduces
Pancreatitis daily PRN pain and fever.
Citalopram 40
(no current meds) antidepressants Increases the amount of serotoin in the
mg PO daily body by preventing the reuptake of
ETOH abuse
(no current meds) serotonin.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 100.6 F/38.1 C (oral) Provoking/Palliative: Movement provokes, nothing relieves pain
P: 98 (regular) Quality: Sharp
R: 20 (regular) Region/Radiation: Epigastric area/LUQ
BP: 146/94 Severity: 10/10
O2 sat: 95% room air Timing: Continuous since onset 24 hours ago
What vital signs are abnormal? What is the reason (pathophysiology) for these findings?
(Reduction of Risk Potential/Health Promotion and Maintenance)
Abnormal VS: Clinical Significance:
increased temp, Elevated BP and slightly elevated pulse and respirations are consistent with
increased BP, the patients pain level of 10/10 for the last 24 hours.
slightly elevated Increased temperature could indicate an infection or a metabolic response
pulse and respiration to the event that has brought her to the hospital.
rate.
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LECTSTEPHEN
Assessment &
Reasoning GI
System
Peggy Scott, 48 years old
Suggested GI/GU Nursing Assessment Skills to Be Demonstrated:
GI/GU:
Inspection: skin (coloration, vascularity, striae, scars, lesions, rashes)
Contour from 2 angles – (flat, rounded, scaphoid, protuberant/distended)
Note symmetry, color, veins, lesions, scars, hair distribution
Umbilicus – contour; Note: inguineal or umbilical hernias
Symmetry (relaxed, supine position)
Abdominal movement during breathing
Aortic pulsations
Auscultation: (completed before palpation/percussion to not alter bowel sounds)
Bowel sounds – 1 minute per quadrant up to 5 minutes with the diaphragm
Intensity, pitch, frequency
Vascular sounds – listen for bruits in abdominal aorta with bell.
Palpation:
Light palpation to all quadrants – 1 to 2 cm to detect tenderness
Deep palpation to all quadrants – 5 to 6 cm for masses (location, size, shape, pulsatility, mobility, tenderness)
Palpate bladder- light palpation ONLY; you only want to assess to see if it is distended
Check for costovertebral angle tenderness
Make Learning Active!
Role play or go through the interview/body assessment process – student to student or as a group.
Review the case study as an application exercise in small groups or together as a class.
Depending on your program, some content in the case study may not have been taught. Do not let that
prevent you from utilizing this case study! Use it to promote learning by having students identify what
they do not yet know and guide where they can find the information in the textbook or on the internet
to address knowledge gaps. This is educational best practice and another way to scaffold knowledge!
Downloaded by: dennys |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
Present Problem:
Peggy Scott is a 48-year old African American woman who came to the emergency department because she is having
severe abdominal pain radiating to the back that started 24 hours ago but has become progressively worse in the last
couple of hours. She is now nauseated and states that she has “puked small amounts of green liquid” five times in the last
four hours. She had two loose stools today that were dark brown or black in color.
Peggy has struggled with ETOH use/abuse most of her adult life but has been sober the past six months. She begins
to cry and tells the nurse that this week was the one-year anniversary of her only son’s death in an automobile accident.
She reports that she has been drinking one liter of vodka daily the past week.
What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
Severe abd pain that radiates to Patient is experiencing severe abdominal pain and is
back vomiting green liquid which may indicate an issue with her
vomiting green liquid x 5 pancreas due to the nature of the pain radiation. Pt has a
loose stool history of ETOH abuse, drinking 1 L of vodka per day. Pt
History of ETOH struggles with depression after loss of her son in MVA
loss of son in MVA
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Class: Mechanism of Action (own words):
Depression Ibuprofen 600 mg NSAIDs inhibits action of prostaglandins, results
Low back pain PO three times in anti-inflammatory response, reduces
Pancreatitis daily PRN pain and fever.
Citalopram 40
(no current meds) antidepressants Increases the amount of serotoin in the
mg PO daily body by preventing the reuptake of
ETOH abuse
(no current meds) serotonin.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 100.6 F/38.1 C (oral) Provoking/Palliative: Movement provokes, nothing relieves pain
P: 98 (regular) Quality: Sharp
R: 20 (regular) Region/Radiation: Epigastric area/LUQ
BP: 146/94 Severity: 10/10
O2 sat: 95% room air Timing: Continuous since onset 24 hours ago
What vital signs are abnormal? What is the reason (pathophysiology) for these findings?
(Reduction of Risk Potential/Health Promotion and Maintenance)
Abnormal VS: Clinical Significance:
increased temp, Elevated BP and slightly elevated pulse and respirations are consistent with
increased BP, the patients pain level of 10/10 for the last 24 hours.
slightly elevated Increased temperature could indicate an infection or a metabolic response
pulse and respiration to the event that has brought her to the hospital.
rate.
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